12 Chapter 1 The impact of HSP on gait HSP-related signs and symptoms impact on all three requirements of purposeful walking: In general, people with HSP show a reduced gait speed and reduced step length in comparison to healthy controls.31,32 From the early stages of HSP, increased trunk movements during gait can be observed. Previous studies have reported on this phenomenon, though it is not completely clear how these enhanced trunk movements should be interpreted. Presumably, the increased trunk movements are generated to improve foot clearance and step length, but there may be additional explanations.33,34 Step width can initially be increased as a compensation to aid balance. Yet, when HSP progresses, hip adductor spasticity increases, which often causes a narrowing of step width. This can result in scissoring gait; a gait pattern in which the legs cross each other.32,33,35 Furthermore, due to spasticity and progressive shortening of the calf muscles, toe walking can be seen; a gait pattern characterized by the absence of heel-to-floor contact.36 Loss of proprioception results in delayed balance responses, while spasticity of the lower extremities, contractures and subsequent ankle foot deformities (e.g. pes equinovarus) may further hinder adequate balance control. Indeed, both feetin-place responses during unperturbed standing, and the ability to make effective balance correcting steps following perturbations can be hampered.37 With respect to gait adaptability, progressive spasticity, muscle weakness and balance impairments may hinder the ability to alter the gait pattern to changing environmental demands. It is therefore understandable that HSP-related signs and symptoms result in reduced gait functioning.16 Impact of HSP on activities and participation in daily life For people with HSP, balance and gait impairments are among their most disabling symptoms.16 It challenges a variety of daily activities, like standing still, stepping over objects, walking on uneven terrain, or getting in and out of a car. This hinders personal hygiene, employment, housekeeping and participation in leisure activities.15 In addition, activities that require standing or walking generally cost people with HSP more effort and energy compared to their peers.15,38 In order to compensate, intensity of daily physical activities is often reduced, or certain activities are ceased completely. A higher severity of gait impairments – specifically when an aid is required to walk – is associated with a reduced quality of life.35,39 As the severity of balance and gait impairments progresses, the risk of falls and fall-related injuries increases: 67% of people with HSP report to fall at least once a year, and in 51%, a fall has led to an injury at least once. It is well known that the experience of a fall may trigger a vicious cycle40-42: due to the fall, people may develop fear-of-falling. Indeed, in the aforementioned study, 73% of people with HSP stated they were moderately to very afraid of falling.16 A fear of falling can
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